AMA study: Alternative medicine growing rapidly
The total number of visits to alternative medicine providers in the United States increased 47% between 1990 and 1997, according to a yearlong study released by the American Medical Association (AMA) in Chicago and published in the Journal of the American Medical Association.
"The trend is clear," says David Eisenberg, MD, of Beth Israel Deaconess Medical Center in Boston, who helped design the study. "Alternative therapy in this country has increased dramatically in the last seven years." Eisenberg reports that 83 million Americans — or 2% of the U.S. adult population — reported using an alternative therapy in the last 12 months. By comparison, a 1990 survey used as a benchmark found that 61 million — or 34% of the U.S. adult population — had used an alternative therapy in the last 12 months.
The total number of visits to alternative medicine providers increased from an estimated 427 million in 1990 to 629 million in 1997, according to the study. To put this in perspective, the researchers report an estimated 388 million total visits to primary care physicians in the United States in 1990, compared with 386 million in 1997.
"The number of visits per person did not change significantly — if anything, it decreased in 1997," Eisenberg says, "so these enormous increases have more to do with the overall increase in the overall population using alternative therapy or seeking professional services, as opposed to an increase in the number of visits per person." The 1997 survey found an average of 16 visits per person, compared to 19 per person in the 1990 study.
Spending for alternative medicine increased at least 45% over this period, according to Eisenberg. Expenditures for these services were "conservatively" placed at $21.2 billion in 1997, but the researchers said a "less conservative" estimate would place expenditures as high as $34 billion. More than half of this expense — $12.2 billion — was paid for out of pocket, a number that exceeded out-of-pocket expenses for all hospitalizations in 1997, the researchers noted.
The study found that almost half of the 629 million visits were for chiropractors (192 million) and massage therapists (114 million). The other most commonly used therapies were herbal remedies and relaxation techniques. The therapies with the most significant increase in usage were relaxation techniques, herbal remedies, massage, spiritual healing, megavitamins, self-help, folk remedies, energy healing, and homeopathy.
Many of the 16 therapies that were examined are deemed "conventional or increasingly mainstream," Eisenberg says. But he adds that the six treatments considered as "more conventional therapies" — biofeedback, hypnosis, guided imagery, lifestyle, diet, relaxation response, and vitamin therapy — accounted for less than 10% of all visits in 1997.
The use of alternative therapies is not confined to any one segment of the population, the study reveals. Use of alternative therapies was significantly more common among women (48.9%) than men (37.8%) and less common among African-Americans (33.1%) than among other racial groups (44.5%).
"The baby boom population was found to use alternative therapy the most," Eisenberg says. Those ages 35 to 49 reported higher rates of use (50.1%) than those older (39.1%) or younger (41.8%). Use was higher among those with college educations (50.6%) than those without (36.4%) and more common among those with annual incomes above $50,000 (48.1%) than those with lower incomes (42.6%). Use was higher in Western states (50.1%) than elsewhere in the country (42.1%).
"In spite of all these dramatic increases in the reach of these alternative medical therapies," he says, "the number of patients that discuss these treatments with their medical physicians remains very low." The number of alternative therapies not discussed with a medical doctor in 1997 was 61%, relatively unchanged from the 60% of alternative therapies that were not discussed with medical doctors in 1990.
"Also troubling is the observation that as many 15 million adults who take prescription medications are also using herbs and high doses of vitamins," Eisenberg adds. "We do not know whether these herbs vitamins and prescriptions interact, so we raise the question of whether 15 million adults are at risk for dangerous interactions.
"The current status quo can easily be described as, Don’t ask and don’t tell,’ and that is not in anybody’s best interest. Physicians need to ask about their patients’ use or interest in alternative therapy, and patients need to discuss this with their physicians."
The majority of alternative therapy in this country continues to be paid for out of pocket entirely, he says, adding that there was no significant change in this over seven years. Because the demand for alternative therapies depends on how much patients must pay out of pocket, he adds, current use is likely to under-represent usage patterns if insurance coverage for alternative medicine increases in the future. The researchers also found that 42% of alternative therapy use is attributed to the treatment of existing illness, while 58% is attributed to prevention and/or health maintenance.
The researchers surveyed 2,055 adults by telephone in 1997 and compared those data with the results of a 1990 telephone survey of 1,539 adults. The 1990 survey used a national random sample and had a response rate of 67%. The 1997 survey also used a national random sample and had a response rate of 60%. "We made no mention of the term alternative medicine,’" Eisenberg says. "It is not important to mention it, because patients don’t see it that way."
An increasing number of U.S. insurance companies and managed care organizations now offer some alternative medicine programs and benefits, and the majority of U.S. medical schools now offer courses in alternative therapies. "In light of these observations," the authors conclude, "we suggest that federal agencies, private corporations, and foundations and academic institutions adopt a more proactive posture concerning the implementation of clinical and basic science research, the development of relevant educational curricula, credentialing and referral guidelines, improved quality control of dietary supplements, and the establishment of postmarket surveillance of drug-herb (and drug-supplement) interactions."
"When it comes to alternative therapies, the AMA has a common-sense message," says Yank Coble, MD, a trustee of the association who presented the AMA’s position on this growing trend. "Either a therapy works and can be proven to work, or it’s untested, unproven and risky."
The AMA’s latest policies on alternative medicine were released as a result of an extensive 1997 Council on Scientific Affairs study, according to Coble. From this study, the AMA concluded: "There is little evidence to confirm the safety or efficacy of most alternative therapies. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies."
"Make no mistake, some alternative therapies and herbal remedies are quackery," Coble says. "They are unproven and ineffective. At best, they are a waste of time and money and, at worst, dangerous and even deadly. Sometimes the alternative therapy itself is dangerous, and other times the delay in getting a proven medicine proves deadly."
Coble adds that, given the growing public interest in alternative medicine as illustrated by the AMA statistics, "accurate, even-handed education about alternative medicine is vital." The bottom line, he says, "is that if standing on your head and rubbing your stomach can be scientifically proven to cure a person’s ills without unacceptable side effects, then there is no reason why that technique cannot or should not be used by the patients and the physicians of America."
Coble notes that 94% of primary care physicians indicate a willingness to refer for at least one alternative therapy, according to a 1996 survey of referral patterns by board-certified family physicians and internists. The therapies most commonly mentioned, he says, were relaxation techniques, biofeedback, and therapeutic massage. "It is a mistake for patients to think a physician would automatically disapprove of a treat - ment outside the mainstream, but it is critical that care be coordinated," he says. "This can only be done if the physician is informed of other therapies being used."
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